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Climbing and Upper Extremity Injuries

Since the first climbing gym in the country was opened in 1987, there has been a

significant increase in popularity for the sport. At this point, there are well over 500 climbing

gyms in the country. 1 It’s even been added to the 2020 summer olympics! With this transition to

mainstream sport, comes the reality that everyone is simply climbing a whole lot more. Instead

of weekend climbing trips we are making daily trips to the gym. Instead of climbing a handful of

routes over the day at the crag, we are climbing a handful of routes in an hour. We can now

meet our friends at the gym every night and socialize while we climb. When we increase these

parameters of climbing harder and more frequently, we increase our risk for injury. When we

work 8 hours at a time and follow it up with several hours of climbing, we increase our risk for

injury. For some reason, maybe it’s the “dirtbag” mindself, climbers do not like asking for

medical help when it comes to an injury. Yes, emphasis on the not . Maybe it’s because we are

expecting the infamous “you should probably stop climbing” statement. I can speak from

personal experience that when I volunteer at climbing gyms, I have a line of climbers that form

almost instantly and that line continues for the next couple hours. It’s endless. I also rarely say

“don’t climb”.

It’s All About Maintenance

When it comes to an injury, unless traumatic, there is often a reason the injury occurs.

Again, unless traumatic, it’s uncommon for something to just come up out of nowhere with no

reason. Think of a car for example. If you don’t perform the necessary maintenance on your

vehicle, the chances of something else breaking down increases. Same thing for your body. If

we don’t maintain our body to meet the demands of the sport, we increase our risk for injury.

The movement involved with a sport has necessary prerequisites that need to be met. For

example, a prerequisite for climbing is to be able to reach straight up over your head without

compensatory movement patterns. Can’t? Why? There could be numerous reasons why most

climbers lack pure overhead reach. Posture is one reason. The next time you are climbing,

watch the belayer. What’s the posture? It’s typically slouched with excessive hinging at the neck

(thank goodness for belay specs). Then, without being a creeper, watch them climb. That

excessive slouch will limit the overhead reach and can also contribute to belayers neck. Have

shoulder pain or belayer's neck? Start with why. It’s postural education and an exercise program

to target postural dysfunction.

Regional Interdependence

There is a term called “regional interdependence” (pictured below). It is where seemingly

unrelated parts of your body causes or contributes to pain elsewhere in your body. Each portion

of the body is connected through chain links (picture 1). They aren’t directly connected but if you

pull on the bottom of the link, it will in some way impact the upper link. It takes a full body

movement screen to determine the root cause of an injury.

Picture 1: Concept of Regional Interdependence

Reference: focusphysio.co.nz/blog/backpainpart1

Tennis Elbow

There are a myriad of climbing-related injuries we can talk about but for the sake of time,

let’s briefly talk about tennis elbow. It may go by different names depending on who you talk to

(i.e. lateral epicondylitis, lateral epicondylalgia, lateral epicondylosis, lateral elbow tendinopathy,

tennis elbow). Different names for different stages of the injury. For the sake of simplicity in this

article, we’ll use tennis elbow.

Anatomy: The Short Version

First, the anatomy. Your forearm, between your elbow and your hand, consists of two

groups of muscles: extensors and flexors. The flexors are on the palm side of your forearm and

extend into your hand and fingers (picture 2). When you squeeze something, it’s primarily your

flexors doing the work. Your extensors are on the opposite side and extend into the back of

your hand and fingers. Most of your flexors connect to the inside of your elbow via one tendon,

the common flexor tendon. The common extensor tendon is similar however it attaches to the

outside of your elbow, or the lateral side. Lateral epicondylitis is inflammation of the common

extensor tendon, where it connects to the lateral epicondyle (lateral aspect of your elbow). The

term -itis can be misleading because it refers to an acute injury where -osis (tendonosis)

typically refers to a chronic condition. Hence the different names for tennis elbow. The elbow is

treated differently based on the stage of injury. For example, the acute stage is typically

identified by the presence of inflammation. The chronic stage presents with a lack of

inflammation, though you may have brief bouts of acute periods. There are many factors that

contribute to how long people are in the acute stage including age, gender, body region, etc.

Picture 2: Anatomy of the Forearm and Elbow

Reference: https://www.rtpelite.com/blog/brace-series/elbow

The Chicken Wing

Now why do so many climbers suffer from tennis elbow? The injury is from overuse of

the extensors of your forearm. The primary action of these muscles is to extend your wrist and

fingers. If you are holding your mouse right now (or typing on your keyboard), keep your wrist

on the table (or pad) and lift your hand off the mouse/keyboard while keeping your forearm

down. This motion is called extension. Now, after reading this you might have wondered why it’s

an extensor injury and not a flexor. After all, we are grabbing in climbing right? When we reach

up for a hold our wrist ideally should be in a neutral position (straight). When we reach up and

pull with an extended wrist, it can place increased stress on your extensors. Why pull with an

extended wrist? Ever heard of the chicken wing in climbers? We’ve all seen it, especially at the

climbing gym. It’s when your elbow sticks out behind you while you are pulling (picture 3). The

more pumped we become, the more the chicken wing starts to show itself. Once the chicken

winging occurs, your wrist is forced into extension and thus increases the demand on your

extensors. Additionally, the tendency to hyperextend your fingers, especially if it’s a crimp,

increases and may overtime contribute to the infamous pulley injury we’ve all heard about.

Picture 3: The Chicken Wing

Reference: https://theclimbingdoctor.com/wp-content/uploads/2015/09/climbing-with-internal-rotation-300x283.png

Muscular Imbalance, Technique, and Training Error

During an injury, we tend to form tunnel vision and focus on the area of pain. With an

acute injury, that’s okay because we need to calm the symptoms down first. However, once that

acute stage is within control, we need to focus on the why. Typically, there are three reasons

we can attribute an injury to: 1) muscular imbalance, 2) technique, 3) training error. Generally,

it’s a combination of the three.

Muscular imbalance for the climber includes strength, flexibility, and coordination. Our

body likes balance. The muscles on one side need to balance the muscles on the other side.

For example, the muscles on the front side of the shoulder need to balance the muscles on the

back side. Another example, the muscles surrounding the shoulder blade need to balance each

other. One side being tighter leads to imbalance. One side being weaker leads to imbalance.

History of injury contributes to further imbalance. Use your left and your right arm differently?

You guessed it, imbalance! Do the same sport or movement over and over again? Imbalance.

This means climbing itself creates imbalance, just like any sport or activity. Sitting at work the

whole day? Imbalance. It is our job to perform routine maintenance on our bodies to return the

balance and equilibrium.

Going back to tennis elbow, as the pump creeps in, that inevitable feeling of your elbow

disappearing somewhere behind you occurs. If you’re reaching up and pulling on a hold, the

elbow should be moving downwards as you pull, not backwards behind you. It's the imbalance

that causes this, creating inefficiency in our movements and excessive stress on certain

structures (common extensor tendon, pulleys, etc). The backside of our shoulder is losing the

battle against the muscles on the front side of our shoulder and that causes the shoulder to

“dump” into internal rotation. The chicken wing that occurs is simply internal rotation of the

shoulder, which is bad in this scenario. Common injuries that we can attribute to this include:

shoulder impingement, tennis/golfers elbow, pulley injuries, flexor tendon injuries

So the treatment for this? Address muscular imbalance, technique, and training errors.

Strengthen and improve the flexibility of the right muscles to create balance and equilibrium.

Technique by being cognizant of what your elbows are doing while climbing. Proper training by

not climbing hard 100% of the time and spending time on the hangboard instead. The pump

isn’t a bad thing. It happens everytime you send a project. It means you’re simply climbing hard.

The pump is an indication that your body is starting to lose control and muscles are becoming

unable to meet the demands you’re placing on it. A marathon runner runs about 6-7 times a

week with only 2-3 “hard” days. The rest are easy days. Climbing is no different.

Movement Screen by the Physical Therapist

A thorough evaluation by a licensed physical therapist (PT) is the best option to address

the muscular imbalance and to discuss activity modification. It takes a full body movement

screen to identify the areas of impairments that contributed to the injury. As climbing injuries

are essentially due to movement faults, an active approach to the rehabilitation will be best. As

a result, a home exercise program will be provided for the climber to perform corrective

exercises at home. Hands-on manual therapy may be performed in conjunction with the

exercises to facilitate healing.

Happy Climbing

References

1) Walsh, M. 2018. The state of climbing gyms in 2018, Climbing, viewed 20 April 2020,

2) 2017. The truth about back pain - part 1, Focus Physio, viewed 21 April 2020,

3) 2019. Recovering from elbow injuries, Return To Play Elite, viewed 21 April 2020,

4) Hsiu, K. 2018. SLAP’d with shoulder injury, The Climbing Doctor, viewed 20 April 2020,